A nurse is assessing a postpartum client for signs of infection.
Which of the following should the nurse report immediately? A) Lochia with clots.
Lochia with clots.
Fundus firmness
Abdominal distension
Breast tenderness.
Temperature greater than 38°C for more than 48 hours.
The Correct Answer is E
The correct answer is choice E) Temperature greater than 38°C for more than 48 hours. This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention. A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.
Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots. However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.
Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding. A soft or boggy fundus can be a sign of infection or hemorrhage.
Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside. However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.
Choice D) Breast tenderness is wrong because some
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["E"]
Explanation
Increased sleepiness and difficulty waking up are signs of central nervous system (CNS) depression in breastfed infants exposed to codeine through breast milk.Codeine is converted into morphine in the body, which can pass into breast milk and cause adverse effects in the baby.Codeine use by breastfeeding mothers can cause CNS depression in breastfed infants.
Therefore, the nurse should watch for increased sleepiness and difficulty waking up in the baby.
Choice A is wrong because increased alertness and activity are not signs of CNS depression.
They are more likely to be signs of stimulation or agitation.
Choice B is wrong because decreased appetite and weight gain are not specific signs of codeine exposure.
They can be caused by many other factors, such as illness, infection, or poor latch.
Choice C is wrong because increased respiratory rate and depth are not signs of CNS depression.
They are more likely to be signs of respiratory distress or infection.
Choice D is wrong because decreased heart rate and blood pressure are not signs of CNS depression.
They are more likely to be signs of shock or hypovolemia.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Respiratory rate: 30 to 60 breaths per minute
Correct Answer is A
Explanation
Naloxone (Narcan) is a specific opiate antagonist that can reverse respiratory depression in newborn infants that may be due to transplacentally acquired opiates.It can be given intravenously, intramuscularly, intraosseously or subcutaneously.The recommended dose is 100 microgram/kg.
Choice B is wrong because nalbuphine (Nubain) is a mixed opiate agonist-antagonist that can cause respiratory depression and withdrawal symptoms in opioid-dependent mothers and infants.
Choice C is wrong because butorphanol (Stadol) is another mixed opiate agonist-antagonist that can have similar effects as nalbuphine.
Choice D is wrong because fentanyl (Sublimaze) is a synthetic opioid that can cause respiratory depression and sedation in both mothers and infants.
Normal ranges for respiratory rate in newborn infants are 30 to 60 breaths per minute.
Normal ranges for oxygen saturation in newborn infants are 90% to 100%.
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